“Vetus Sed Utilis”: Open Window Thoracostomy after Lung Surgery

Abstract

Introduction

Open window thoracostomy (OWT) is an ancient surgical intervention, born for managing chronic thoracic infectious diseases. Our goal is to report our 25-year experience in the management of these patients, focusing on its feasibility and usefulness in our modern era.

Methods

We retrospectively reviewed our database (1999–2024), reporting all clinical preoperative, intraoperative, and postoperative data of patients undergoing OWT for treating chronic empyema, linked to broncho-pleural fistula after lung resection, or not. Data were collected on the type of original surgical intervention, perioperative and postoperative management, 30- and 90-day mortality, overall survival, and following reintervention to close OWT.

Results

Sixty-six OWTs were performed to treat acute and chronic septic complications due to original lung intervention for cancer. OWT was performed for treating a late broncho-pleural fistula after pneumonectomy (56 cases; 85%) or after lobectomy (8 cases; 12%) or pleural chronic empyema (2 cases; 3%). Thirty- and 90-day mortality after OWT following pneumonectomy was 3% (2 patients) and 6% (4 patients), respectively. No 30- and 90-day death was observed in the other patients. In 15 out of 66 patients (22.7%), OWT was closed by muscle, skin, or omentum flaps. No statistical differences were observed comparing the survival of the patients undergoing or not undergoing OWT closure, after pneumonectomy (p = 0.59).

Conclusion

OWT is a safe, feasible, and sometimes mandatory technique for the management of chronic infectious issues linked to broncho-pleural fistula (BPF) after lung surgery. It is well tolerated by guaranteeing an appropriate quality of life.

Keywords

lung cancer - broncho-pleural fistula - lung surgery - pneumonectomy - open window thoracostomy

Publication History

Received: 27 March 2025

Accepted: 13 May 2025

Article published online:
05 June 2025

• References

• 1 Eloesser L. Of an operation for tuberculous empyema. Ann Thorac Surg 1969; 8 (04) 355-357
• 2 Clagett OT, Geraci JE. A procedure for the management of postpneumonectomy empyema. J Thorac Cardiovasc Surg 1963; 45: 141-145
• 3 Dewan RK. Surgery for pulmonary tuberculosis - a 15-year experience. Eur J Cardiothorac Surg 2010; 37 (02) 473-477
• 4 Katsuragi N, Shiraishi Y, Nakajima Y, Kurai M, Takahashi N. Evaluation of open window thoracostomy for chronic tuberculous empyema with broncho-pleural fistula; a retrospective analysis of 33 cases [in Japanese]. Kyobu Geka 2005; 58 (03) 175-180 , discussion 181–183
• 5 Symbas PN, Nugent JT, Abbott OA. et al. Non tuberculous pleural empyema in adults. Ann Thorac Surg 1971; 12: 69-78
• 6 Gradica F, Lisha L, Argjri D. et al. P1.31: Pleural Empyema and broncho pleural fistula after lung resection: analyses of 29 patients treated in our clinic. J Thorac Oncol 2016; 11 (10S): S201
• 7 Goldstraw P. Treatment of postpneumonectomy empyema: the case for fenestration. Thorax 1979; 34 (06) 740-745
• 8 García-Yuste M, Ramos G, Duque JL. et al. Open-window thoracostomy and thoracomyoplasty to manage chronic pleural empyema. Ann Thorac Surg 1998; 65 (03) 818-822
• 9 Shamji FM, Ginsberg RJ, Cooper JD. et al. Open window thoracostomy in the management of postpneumonectomy empyema with or without bronchopleural fistula. J Thorac Cardiovasc Surg 1983; 86 (06) 818-822
• 10 Noh D, Park CK. The management of delayed post-pneumonectomy broncho-pleural fistula and esophago-pleural fistula. Korean J Thorac Cardiovasc Surg 2016; 49 (02) 138-140
• 11 Regnard JF, Alifano M, Puyo P, Fares E, Magdeleinat P, Levasseur P. Open window thoracostomy followed by intrathoracic flap transposition in the treatment of empyema complicating pulmonary resection. J Thorac Cardiovasc Surg 2000; 120 (02) 270-275
• 12 Deschamps C, Pairolero PC, Allen MS, Trastek VF. Management of postpneumonectomy empyema and bronchopleural fistula. Chest Surg Clin N Am 1996; 6 (03) 519-527
• 13 Miller JI, Mansour KA, Nahai F, Jurkiewicz MJ, Hatcher Jr CR. Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication. Ann Thorac Surg 1984; 38 (03) 227-231
• 14 Mazzella A, Pardolesi A, Maisonneuve P. et al. Bronchopleural fistula after pneumonectomy: Risk factors and management, focusing on open-window thoracostomy. Semin Thorac Cardiovasc Surg 2018; 30 (01) 104-113
• 15 Hysi I, Rousse N, Claret A. et al. Open window thoracostomy and thoracoplasty to manage 90 postpneumonectomy empyemas. Ann Thorac Surg 2011; 92 (05) 1833-1839
• 16 Weissberg D, Refaely Y. Empyema and bronchopleural fistula: experience with OWT. Chest 1982; 82: 447-450
• 17 Mazzella A, Bertolaccini L, Sedda G. et al. Pneumonectomy and broncho-pleural fistula: Predicting factors and stratification of the risk. Updates Surg 2022; 74 (04) 1471-1478
• 18 Wotton R, Garner M, Salem A, Buderi S. Is open window thoracostomy the only method to control infection in patients with an empyema following pulmonary resection for primary lung cancer?. Interact Cardiovasc Thorac Surg 2021; 32 (06) 928-932
• 19 Massera F, Robustellini M, Della Pona C, Rossi G, Rizzi A, Rocco G. Open window thoracostomy for pleural empyema complicating partial lung resection. Ann Thorac Surg 2009; 87 (03) 869-873
• 20 Sziklavari Z, Ried M, Zeman F. et al. Short-term and long-term outcomes of intrathoracic vacuum therapy of empyema in debilitated patients. J Cardiothorac Surg 2016; 11 (01) 148
• 21 Mazzella A, Casiraghi M, Uslenghi C. et al. Bronchopleural fistula after lobectomy for lung cancer: How to manage this life-threatening complication using both old and innovative solutions. Cancers (Basel) 2024; 16 (06) 1146
• 22 Pairolero PC, Arnold PG, Trastek VF, Meland NB, Kay PP. Postpneumonectomy empyema. The role of intrathoracic muscle transposition. J Thorac Cardiovasc Surg 1990; 99 (06) 958-966 , discussion 966–968